Reconstruction of complex oro-mandibular defects by four different modifications of free fibula osteomyocutaneous flap: A prudent alternative to multiple flaps

Factors affecting anastomosis failure in microvascular fibula flap reconstruction of the maxillofacial region: a systematic review and meta-analysis

This systematic review and meta-analysis evaluates the contributory factors and failure rates in anastomosis during microvascular fibula flap reconstruction in maxillomandibular regions. A comprehensive search strategy was employed across databases including MEDLINE, Web of Science, EMBASE, Scopus, Cochrane's CENTRAL, as well as grey literature sources, and manual searches of noteworthy journals, covering studies from inception up to April 2023. The inclusion criteria targeted retrospective or prospective cohort and clinical studies that investigated functional and dental rehabilitation outcomes in human subjects undergoing maxillofacial reconstruction using microvascular fibula flaps. Exclusion criteria encompassed case-control studies, alternative reconstruction method research, and animal-based investigations. The study's findings revealed a cumulative vascular failure rate of 6%. Subsequent analysis delineated the primary causes of this failure, attributing 3% to venous thrombosis, 1% to arterial thrombosis, and less than 1% to blood vessel compression due to hematoma. However, notable heterogeneity across the studies indicates substantial variability in vascular failure rates reported. These results of our review and meta-analysis underscore the intricate factors impacting anastomosis success, such as anastomosis technique, recipient vessel quality, the choice between couplers.

The fusiform skin paddle in fibula free flap: a fusiform-designed skin paddle for maxillofacial soft defect reconstruction and reducing leg wound tension

Objective

To investigate the feasibility of leg wound closure and reconstruction of maxillofacial soft defect by a fusiform-designed skin paddle in fibula free flap (FFF).

Methods

Fifty patients who underwent FFF for reconstruction of maxillofacial soft defect were divided into two groups. The fusiform group (20 patients) was treated using a fusiform-designed skin paddle in FFF (skin paddle width less than 2 cm), and leg wound was closed using primary suturing. Reconstruction of the maxillofacial soft defect or filling of dead space was achieved by folding the fusiform skin paddle. The conventional group (30 patients) was treated using the conventional-designed skin paddle (skin paddle width no less than 2.5 cm). The leg wound was closed using mattress suturing or skin graft, while reconstruction of the maxillofacial soft defect or filling of dead space by conventional way. The average postoperative length of hospital stay, healing time of leg wound, and post-surgical complications were recorded at least 6 months after the surgery.

Results

Compared with traditional method, the fusiform-designed skin paddle reduced the average healing time of the leg wound (fusiform group: 11.05 days, conventional group: 14.77 days, P < 0.05). The average length-to-width ratio in fusiform group was significantly greater than that of in conventional group (fusiform group: 5.85, conventional group: 2.93, P < 0.05), and no difference was observed on the graft size of skin paddle between two groups (fusiform group: 23.13, conventional group: 27.13, P > 0.05). The post-surgical early complications of the leg wound in the conventional group were higher than that of in the fusiform group (fusiform group: 0%, conventional group: 6.67%), while the post-surgical late complication of the donor site between the two groups showed no case. Healing disorders of maxillofacial soft reconstruction in the conventional group were higher than that of in the fusiform group (fusiform group: 5.26%, conventional group: 20.69%).

Conclusions

Fusiform-designed skin paddle for closure of the leg wound and maxillofacial soft defect is a feasible alternative to the conventional- designed skin paddle. The fusiform- designed skin paddle resulted in the less postoperative length of hospital stay, shorter healing time of leg wound and less complication.

Segmental Mandibulectomy and Mandibular Reconstruction with Fibula-Free Flap Using a 3D Template

INTRODUCTION

The present study evaluates the influence of virtual surgical planning with a preoperative 3D resin model on aesthetic and functional outcomes in patients treated by segmental mandibulectomy and reconstruction with fibula-free flap for oral cancer.

METHODS

All consecutive patients who underwent segmental mandibulectomy and mandibular reconstruction with a fibula-free flap using a 3D template at our department from January 2021 to January 2023 were included in the study. "Patients control" were patients treated by reconstruction with a fibula-free flap without using a 3D template. Three-dimensional modeling was performed by converting from preoperative computed tomography to a stereolithography format to obtain the resin 3D models. Qualitative analysis of anatomical and aesthetic results consisted of the evaluation of the patients' aesthetic and functional satisfaction and the symmetry of the mandibular contour observed at clinical examination. Quantitative analysis was based on the assessment of the accuracy and precision of the reconstruction by comparing preoperative and postoperative computed tomograms as objective indicators.

RESULTS

Seven patients (five males and two females, mean age of 65.1 years) were included in the study. All patients showed a symmetric mandibular contour based on the clinical examination. After recovery, six patients (85.7%) considered themselves aesthetically satisfied. The quantitative analysis (assessed in six/seven patients) showed that the mean difference between preoperative and postoperative intercondylar distance, intergonial angle distance, anteroposterior dimension, and gonial angle improved in the 3D template-assisted group.

CONCLUSION

The 3D-printed template for mandibular reconstruction with microvascular fibula-free flap can improve aesthetic outcomes in comparison with standard approaches.

Introduction and preliminary application report for a novel 3D printed perforator navigator for fibular flap surgery

The aim of this study was to introduce and report on a 3D-printed perforator navigator and its clinical application. Integrated imaging and 3D printing techniques were employed for the design and manufacture of a perforator navigator. Key techniques included establishing a digital image coordinate system, localizing perforator fascia piercing points, creating a reference plane for the perforator course, and projecting the perforator course onto the body surface. All cases of maxillofacial defect repaired with free fibular myocutaneous flaps, from January 2019 to January 2022, were reinvestigated. Patients treated using traditional perforator localization methods were assigned into group Ⅰ, while those who had a navigator used during treatment were allocated to group Ⅱ. Outcome measurements included perforator positioning accuracy, perforator preparation time (PT), and flap growth score. Capillary refilling time and degree of flap swelling were recorded on the 1st, 3rd, and 7th days after surgery. On the 10th day after surgery, the flap survival situation was graded. In total, 25 patients were included in the study. Perforator preparation time for group Ⅱ was significantly less (p ＝ 0.04) than for group Ⅰ (1038.6 ± 195.4 s versus 1271.4 ± 295.1 s. In group Ⅱ, the mean positioning deviation for the perforator navigator was 2.12 cm less than that for the high-frequency color Doppler (p ＝ 0.001). Group Ⅱ also had a higher score than group Ⅰ for overall flap growth evaluation (nonparametric rank sum test, p ＝ 0.04). Within the scale of the study, it seems that perforator localization and navigation using a 3D-printed navigator is technically feasible, and helps to improve the clinical outcome of free fibular flaps. The perforator navigator will play a useful role in displaying the perforator course, improving the accuracy of perforator localization, reducing surgical injury, and ultimately enhancing flap success rate.

Application of a modified osteotomy and positioning integrative template system (MOPITS) based on a truncatable reconstruction model in the precise mandibular reconstruction with fibula free flap: a pilot clinical study

BACKGROUND

Mandibular defects can greatly affect patients' appearance and functionality. The preferred method to address this issue is reconstructive surgery using a fibular flap. The current personalized guide plate can improve the accuracy of osteotomy and reconstruction, but there are still some problems such as complex design process and time-consuming. Therefore, we modified the conventional template to serve the dual purpose of guiding the mandible and fibula osteotomy and facilitating the placement of the pre-bent titanium.

METHODS

The surgery was simulated preoperatively using Computer-Aided Design (CAD) technology. The template and truncatable reconstruction model were produced in the laboratory using 3D printing. After pre-bending the titanium plate according to the contour, the reconstruction model was truncated and the screw trajectory was transferred to form a modified osteotomy and positioning integrative template system (MOPITS). Next, the patient underwent a composite template-guided vascularized fibula flap reconstruction of the mandible. All cases were reviewed for the total operative time and accuracy of surgery.

RESULTS

The procedures involved 2-4 fibular segments in 15 patients, averaging 3 fibular segments per procedure. The osteotomy error is 1.01 ± 1.02 mm, while the reconstruction angular error is 1.85 ± 1.69°. The preoperative and postoperative data were compared, and both p > 0.05. During the same operation, implant placement was performed on four patients, with an average operative time of 487.25 ± 60.84 min. The remaining malignant tumor patients had an average operative time of 397.18 ± 73.09 min. The average postoperative hospital stay was 12.95 ± 3.29 days.

CONCLUSIONS

This study demonstrates the effectiveness of MOPITS in facilitating precise preoperative planning and intraoperative execution of fibula flap reconstruction. MOPITS represents a promising and reliable tool for reconstructive surgery, particularly for inexperienced surgeons navigating the challenges of mandible defect reconstruction.